Intake Flashcards
ROS: generals
fever, chills, weight loss or gain, temperature intolerance, fatig
ROS: HEAD
headache, changes in mood, depression, anxiety, psychological diagnoses
ROS: EYES
diplopia, blurry, pain, changes in acuity
ROS:EARS
tinnitus, changes in hearing, dizziness, pain
ROS:NOSE
able to breathe through nose, blood noses, discharges, change in smell
ROS: MOUTH
sores, bleeding gums, dental caries, root canals, TMJ, change in taste
ROS:THROAT
dysphagia, acid reflux, sore throat, changes in voice, swollen nodes
ROS: CV
chest pain, palpitations, swelling, varicosities, cold extremities, bruise easily
ROS:RESP
cough, wheezing, DoE, SoB, snoring, wake feeling tired
ROS:GI
indigestion, gas, diarrhea/constipation, nausea/vomiting, halitosis stools (number, colour, consistency, ease of passing), abdominal pain
ROS: URINARY
frequency, urgency, pain, blood, forked stream, ease of passing
ROS:MALE
ability to achieve and maintain erection, ability to climax, pain with sex any skin changes to genitalia, form of birth control, men/women/both,
oral/anal/vaginal, number of sexual partners
ROS: GYN
LMP, G/P, regularity of menses, form of birth control, men/women/both, oral/anal/vaginal, number of sexual partners, history of breast masses
ROS: M.S
pain, achiness, stiffness in joints or muscles, atrophy, weakness, RoM history of broken bones, torn ligaments, headache, neck pain
ROS: NEURO
balance, tingling, numbness, feeling confused, tremor, changes in memory
ROS:ENDO
temperature tolerance, changes to skin texture/hair/nails, sweating, changes in menses
What topics does ROS consist of?
SEAMMS general skin HEENT heary lungs GI GU repro M.S Endo psy
Main aspects of a chart note
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Hpi - LMNOPQRST +constiutionsal, conmomitanty, discharge
PMHx FHx SHx Diet ROS
